Breast Reconstruction: What's Best For You?

Who should consider breast reconstruction – and who’s not a candidate? What type is best – and why? An overview of current breast reconstruction options, with advice on how to make your best choice.

You’ve been diagnosed with breast cancer. Tests have indicated you need a mastectomy. Your surgeon asks if you’re interested in reconstruction.

Reconstruction – what’s that?

Before visions of heavy equipment and guys in hard hats start dancing through your head, understand this: breast reconstruction is simply replacing your soon-to-be-gone breast with a reasonable facsimile, one that lives under your skin and, aside from up close and personal moments, looks normal – especially under your clothes.

Post-mastectomy: you have a decision to make

When you have a mastectomy, you have three basic choices for next steps.

First, you can choose to simply live with a flat place on your chest where your breast used to be.

Second, you can leave your chest flat, but fill the space with an external prosthesis, or breast form: a soft, breast-shaped piece of fiberfill or silicone that rests in a special bra, evening out your contour.

Each of these choices comes with pluses and minuses. It’s up to you to identify and weigh those, then decide what’s most important to you; you can then choose which option is best for you.

First of all, the decision might be taken out of your hands: women with certain underlying health issues or lifestyle choices (diabetes, smoking) are generally ineligible for certain types of reconstruction: mainly body tissue. So your initial discussion with the surgeon will include a complete rundown of your overall health, and exactly which type(s) of reconstruction you qualify for.

Consider recovery time

If your surgeon says everything’s on the table, ask about the recovery time for each option. If you absolutely can’t take more than a certain number of weeks off work; or can’t be absent from family responsibilities for the amount of time any particular procedure might take, then you might rule those options out.

Generally speaking, a mastectomy without reconstruction has the quickest recovery time. You’ll probably spend 24 to 48 hours in the hospital, then be asked to “take it easy” as your scar heals.

The initial surgery for an implant has a fairly short recovery time, but there can be a months-long lead-up to that surgery, involving regular “fills” with saline to stretch your breast skin. Each of those fills involves a trip to the doctor, as well as discomfort potentially great enough to keep you out of commission for a few days.

Some surgeons offer a newer procedure, an immediate implant without the months of preparation. Obviously this procedure, which involves artificial skin, is less time-consuming; ask your surgeon if s/he performs it.

Implants have a “shelf life” of about 10 to 12 years; so understand that if you choose an implant, you’re facing another surgery at some point down the road.

Having a body tissue reconstruction will put you in the hospital for up to a week; then out of action (think of it as light duty: no lifting, no reaching, no driving) for several weeks once you’re home. But once you get through those first 2 to 4 to 6 weeks (we each heal at our own rate), you won’t have to worry about your new breast for the rest of your life.

One more thing to consider: if your cancer is aggressive and your oncologist wants you to start further treatment right away, this may influence your reconstruction choice. Thankfully, if you need to start treatment ASAP, you can still have reconstruction – up to months or even years later.

How’s your pain tolerance?

Do you have a greater-than-normal fear of pain? Then make that part of your decision process. No one can predict the amount of pain any procedure will give you, but in general, the less aggressive and extensive the surgery, the less pain you’ll have.

A simple mastectomy without reconstruction is probably the least painful option. If you’ve ever had major surgery before, you know that the greatest pain occurs directly after the surgery, and gradually lessens as your scar heals.

The implant process can be quite painful, off and on, for several months; both due to the pre-implant fill procedure, and to your body adapting to a foreign object – the implant – post-surgery.

With body tissue reconstruction, some women report considerable pain post-surgery and then for weeks afterwards, particularly after a double mastectomy. Others report post-surgery pain that diminishes quickly and disappears completely within a week or so.

Can you afford it?

Even if you’re eligible for any type of reconstruction you want, finances might play a role in your final choice.

Thankfully, if you have private health insurance (not Medicare/Medicaid), the government mandates that if insurance pays for your mastectomy, it must pay for breast reconstruction. The federal Women’s Health and Cancer Rights Act of 1998 states the following:

“Under WHCRA, group health plans, insurance companies and health maintenance organizations (HMOs) offering mastectomy coverage must also provide coverage for reconstructive surgery in a manner determined in consultation with the attending physician and the patient. Coverage includes reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, and prostheses and treatment of physical complications at all stages of the mastectomy, including lymphedemas.”

If you’re covered under Medicare/Medicaid, check with those agencies for current coverage; you may (or may not) be in luck.

If you’re having a body tissue reconstruction, your surgeon will look at your body to determine the best site for “harvesting” tissue to move to your chest. This tissue might come from your abdomen, buttocks, thighs, or the top of your back, near your shoulder blades.

The surgeon will also ask a few questions about your health and lifestyle, like “Do you plan on becoming pregnant?” And “How important to you is abdominal strength vs. shoulder strength?”

After collecting this information, he or she will then make a recommendation based on your body type. If possible, most women opt for a procedure using belly fat, since you get a “tummy tuck” at the same time. But some slimmer women don’t have sufficient belly fat, and must use tissue from another part of the body.

As for the surgery itself, you may hear about TRAM flap, DIEP flap, SIEP flap, and other types of operations; suffice it to say all involve moving tissue from one part of your body to your chest, and differ mainly in how that move is accomplished. Your surgeon may or may not have the skills to perform all of the different options; s/he will recommend the one s/he feels best suits your needs, and is within his or her capability as a surgeon.

Bottom line

Breast reconstruction is very “personal” surgery, given that it’s mostly about body image. Only you can make this decision about your body. While it’s natural to discuss options with your significant other, don’t let yourself be talked into something you’re not comfortable with. At the end of the day, you’re the one who gets to decide if you want a new breast, a removable prosthesis – or nothing at all.

Breast cancer survivor and award-winning authorPJ Hamel_, a long-time contributor to the HealthCentral community, counsels women with breast cancer through the volunteer program at her local hospital. She founded and manages a large and active online survivor support network. _

PJ Hamel is senior digital content editor and food writer at King Arthur Flour, and a James Beard award-winning author. A 16-year breast cancer survivor, her passion is helping women through this devastating disease. She manages a large and active online survivor support network based at her local hospital and shares her wisdom and experience with the greater community via HealthCentral.com.